Remote Clinical Documentation Improvement (CDI) Nurse – RN – Compact License

Clinical Documentation Improvement (CDI) Nurse

Location: 100% Remote

Schedule: Monday-Friday | 40 hours/week

Contract: 6-Month Contract-to-Hire

Pay: $50-$55/hour

Start Date: ASAP

Equipment: Provided

Job Description

Medasource is seeking an experienced Clinical Documentation Improvement (CDI) Nurse for a fully remote, 6-month contract-to-hire opportunity supporting a large healthcare organization.

The CDI Nurse will conduct concurrent and retrospective reviews of inpatient medical records to identify documentation opportunities, improve clinical accuracy, and support appropriate severity of illness, risk of mortality, quality outcomes, and reimbursement. This individual will work closely with physicians, CDI specialists, coding teams, and other clinical professionals to ensure documentation accurately reflects the patient’s condition and complexity of care.

Responsibilities

• Conduct concurrent and retrospective reviews of inpatient medical records
• Identify clinical documentation gaps and opportunities for improvement
• Initiate compliant physician queries for missing, conflicting, or unclear documentation
• Review documentation for accurate MS-DRG and APR-DRG assignment
• Evaluate documentation related to Severity of Illness (SOI) and Risk of Mortality (ROM)
• Support focused reviews involving mortality, PSI, HAC, and other quality measures
• Collaborate with physicians, coding/HIM teams, and CDI leadership
• Help ensure accurate documentation supporting CMI, LOS, reimbursement, and quality outcomes
• Educate providers on CDI best practices and documentation requirements
• Participate in CDI initiatives and documentation improvement projects

Qualifications

• Active RN license required; Compact RN license accepted
• 3-5 years of CDI experience preferred
• Strong inpatient/acute-care clinical background
• Experience conducting inpatient concurrent reviews and physician queries
• Knowledge of MS-DRGs, APR-DRGs, SOI, ROM, CMI, PSI, and HAC
• Strong understanding of clinical documentation, coding guidelines, quality outcomes, and reimbursement
• Strong communication skills and experience collaborating with physicians and coding teams
• Ability to work independently in a fully remote environment

Preferred Qualifications

• Previous ICU, Emergency Department, or other high-acuity nursing experience
• CCDS or CDIP certification
• Clinical Documentation Excellence (CDE) experience
• Epic experience
• Provider education and engagement experience

CCDS and coding certifications are not required for this opportunity.